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MUTTER 


1900 


JOHN  B.  ROBERTS,  M.D. 


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THE  SURGICAL  TREATMENT  OF  CON^ 

GENITAL  AND  PATHOLOGICAL 

DISFIGUREMENTS  OF 

THE  FACE. 

ABSTRACT  OF  THE 

MUTTER  LECTURES  OF  THE  COLLEGE  OF 

PHYSICIANS  OF  PHILADELPHIA, 

FOR  1900. 


BY 

JOHN  B.  ROBERTS,  A.M.,  M.D. 

Professor  of  Surgery  in  the  Philadelphia  Polyclinic,  Surgeon  to  the 
Methodist  Hospital. 


fi^: 


h. 


PHILADELPHIA  : 

THE  PHILADELPHIA  MEDICAL  PUBLISHING  CO. 

1900. 


0  AJ 


/  9o  o 


CONTENTS. 


Lecture  I. 

PAGE. 

A  Brief  Eeyiew  of  the  Development  of  Reparative  or  Plastic 
Surgery 1 

Lectuee  II. 
A  Rapid  Survey  of  the  Anatomy  of  the  Human  Face 4 

Lecture  III. 

Characteristics  of  Surgery  in  the  Face. — The  Principles  of  Plastic 
Surgery  of  the  Face 10 

Lecture  IV. 
The  Removal  of  Disfigurements  Due  to  Pigments,   Cicatricial 
Distortions,  Errors  of  Development,  Tumors  and  Skin  Dis- 
eases   12 

Lecture  V. 
Deformities  of  the  Lips  and  Mouth 17 

Lecture  VI. 
The  Reconstruction  of  the  Lips  and  Cheeks -.20 

Lecture  VII. 
The  Correction  of  Deformed  Noses 26 

Lecture  VIII. 
The  Construction  of  New  Noses 34 

Lecture  IX. 
The  Operative  Treatment  of  Deformed  or  Deficient  Ears   ....    42 

Lecture  X. 
The  Cosmetic  Surgery  of  the  Eyes 47 


/ 


DELPHIA  rMEI 


[Reprinted  from  The;j*hiladelphia:Medical  Journal. J 


^ 


■X, 


MUTTER  LECTURES  OF  THE  COLLEGE  OP  PHYSICL^NS 
OF  PHILADELPHIA.. 

The  Surgical  Treatment  of  Congenital  and  Pathologic 
Disfigurements  of  the  Face. 

By  JOHN  B.  EGBERTS,  M.D. 

Professor  of  Surgery  in  the  Philadelphia  Polyclinic. 

Lecture  I. — A  Brief  Revieiv  of  the  Development  of  Repar- 
ative or  Plastic  Surgery. 

[Abstract.] 

It  is  often  forgotten  that,  until  the  revival  of  plastic 
operations  upon  the  face  about  the  year  1800,  recon- 
structions of  lost  areas  of  tissue  and  readjustments  of 
textural  relations  by  operation  had  been  practically 
unknown  to  the  scientific  world  for  a  couple  of  cen- 
turies. The  operative  methods  of  Tagliacozzi  at  Bologna 
detailed  in  his  book,  published  in  1597,  and  the 
methods  employed  for  many  centuries  in  India  for 
restoring  mutilations  of  the  nose  had  been  forgotten  or 
disbelieved.  Carpue  in  England  and  Graefe  in  Ger- 
many aroused  surgical  attention  to  plastic  surgery  in 
the  second  decade  of  the  nineteenth  century.  It  was 
rhinoplastic  operations  that  were  particularly  advocated 
by  these  surgeons  and  their  colleagues,  and  which  gave 
birth  to  a  knowledge  of  the  physiological  possibilities  of 
reparative  surgery. 

About  this  time  public  attention  was  called  to  rhino- 
plastic  operations  by  a  number  of  writers  on  non-medical 
subjects.  Dr.  Ferriar  in  his  "Illustrations  of  Sterne 
with  other  Essays  and  Verses,"  published  in  1798,  said 
truly  that  Sterne  in  his  novel  "Tristram  Shandy'" 
should  have  included  among  his  allusions  to  the  nose, 
taken  from  literature,  the  operations  of  Tagliacozzi. 
Ferriar  says  that  the  Italian  surgeon  was  the  more 
entitled  to  notice  because  his  fame  had  been  unjustly 
and  unaccountably  eclipsed.  Ferriar  in  his  enthusiasm 
describes  in  detail  the  operation  of  rhinoplasty  and 


compares  the  physiological  deductions  of  the  Italian 
surgeon  with  those  of  John  Hunter.  Hunter  had  died 
only  five  years  before  the  publication  of  the  "  Illustra- 
tions of  Sterne  "  and  his  experiments  on  grafting  tissues 
were  evidently  known  to  Ferriar.  The  latter  lays  much 
stress  upon  the  fact  that  in  Tagliacozzi's  time  the  arteries 
were  supposed  to  be  full  of  air  and  that  the  circulation 
of  the  blood  was  unknown  to  him ;  and  that  the  Italian 
investigator's  views  on  the  method  of  union  of  living 
parts  are  exceedingly  interesting  and  remarkably 
accurate.  The  Gentlemen's  Magazine  of  1794  and  Pen- 
naafs  Views  of  Hindoostan,  published  about  the  same 
time,  give  accounts  of  the  reconstruction  of  noses  from 
the  forehead  performed  in  India  to  relieve  the  horrid 
facial  disfigurements  so  common  in  that  country. 
Amputation  of  the  nose  was  there  frequently  performed 
as  a  punishment  to  prisoners  and  as  retribution  for 
supposed  marital  unfaithfulness. 

It  is  curious  to  read  at  the  present  time  the  doubt 
felt  by  Hiester,  Coote,  and  other  surgical  writers  of 
more  or  less  recent  date,  as  to  the  possibility  of  rhino- 
plastic  operations.  This  doubt  of  the  professional  mind 
is  a  little  difficult  to  understand,  when  it  is  recollected 
that  there  was  even  then  a  considerable  amount  of 
literature  showing  the  possibility  of  the  adhesion  of 
parts,  entirely  separated  from  the  body,  if  they  were 
reapplied  and  sutured  within  a  reasonable  time. 

In  1823  Biinger,  of  Marburg,  made  a  new  nose  for  a 
woman  from  the  tissue  of  her  thigh.  In  Europe,  Dief- 
fenbach,  Graefe,  Blandin,  Serre,  Jobert  and  Zeis  were 
earnest  advocates  of  reparative  surgery.  In  America, 
Warren,  Mutter  and  Pancoast  were  the  early  advocates 
of  plastic  operations.  Thomas  D.  Mutter,  the  founder  of 
the  Mutter  Museum  and  the  Mutter  Lectureship,  pub- 
lished articles  on  plastic  surgery  a  very  few  years 
after  his  graduation  in  1831.  They  were  followed  by 
other  American  surgeons,  among  whom  may  be  men- 
tioned as  conspicuous  operators  Post,  Buck,  Andrews 
and  Prince. 

Szymanowski,  of  Russia,  published  in  1867  an 
elaborate  attempt  to  systematize  the  various  oper- 
ative procedures  for  the  relief  of  deformities  requir- 
ing   plastic    surgery.      He    devoted   many    pages    of 


his  operative  surgery  to  illustrations  showing  the 
principles  upon  which  the  integuments  can  be  satis- 
factorily displaced.  His  experiments  on  the  cadaver 
aided  him  very  much  in  the  preparation  of  this 
part  of  his  book,  which  has  become  a  classic.  A 
decided  advance  was  made  in  1871  by  Reverdin,  who 
proposed  epidermic  grafting,  often  called  skin-graft- 
ing, for  covering  ulcers  and  granulating  wounds. 
Other  steps  in  the  progress  of  reparative  surgery  were 
the  announcement  by  Thiersch,  in  1886,  of  his  method 
of  transplanting  large  shavings  of  the  upper  layers  of 
the  skin.  Previous  to  this  time,  however,  Wolfe,  of 
Glasgow,  had  shown  that  moderate  size  pieces  of  skin 
could  be  transplanted  without  a  pedicle  with  compar- 
ative certainty  of  union.  Krause  has  greatly  improved 
the  method  of  transplanting  skin  without  pedicles. 

Other  steps  in  reparative  surgery  are  the  substitution 
of  muscles  for  those  torn  away  by  accident  or  paralyzed, 
the  transference  of  nerve-trunks,  and  similar  proced- 
ures. Among  the  most  interesting  are  the  substitution 
by  Czerny  of  a  fatty  tumor  from  the  thigh  for  a  portion 
of  the  mammary  gland  which  had  been  excised  for 
malignant  tumor.  Gluck  has  succeeded  experiment- 
ally in  repairing  a  defect  of  the  carotid  artery  by  patch- 
ing that  vessel  with  a  piece  of  jugular  vein.  Van  Lair 
has  suggested  the  possibility  of  taking  portions  of 
organs,  or  possibly  whole  organs,  at  the  moment  of 
death  and  using  them  for  the  restoration  of  internal 
parts.  The  thyroid  gland  of  the  sheep  has  been  im- 
planted in  the  abdomen  of  man  to  act  as  a  substitute 
for  his  diseased  or  extirpated  thyroid  gland.  The 
ovary  has  been  transplanted  successfully,  from  one 
animal  to  another  and  from  one  region  to  another  of 
the  same  animal.  It  is  said  that  such  ovaries  have 
carried  on  their  function  and  even  made  pregnancy 
possible. 

Nicoladoni  has  recommended,  for  the  loss  of  the 
thumb,  the  grafting  of  a  toe  upon  the  hand.  Glass 
balls  have  been  introduced  into  the  eye  to  represent 
the  vitreous  humor  and  maintain  the  globular  shape  of 
the  organ.  Celluloid  and  metal  supports  are  worn 
within  the  tissues  of  the  nose  to  give  them  a  proper 
shape.     The  mental  distress  of  despondent  men  has 


been  relieved  by  tbe  substitution  of  similar  materials 
for  extirpated  testicles.  This  "  implantation-therapy  " 
is  susceptible  of  far  greater  use  than  is  yet  realized. 

Lecture  II. — A    Rapid   Survey  of  the  Anatomy  (Con- 
structive, Regional,  and  Artistic)  of  the  Human  Face. 

[Abstract.] 

The  frontal  and  temporal  regions  of  the  cranium 
must  be  included  in  the  present  study  ;  because  the  dis- 
figurements to  be  considered  concern  the  ears  and  fore- 
head, as  well  as  that  portion  of  the  head  usually  called 
the  face  in  anatomical  treatises. 

Good  surgery  of  any  region  is  impossible  without  a 
knowledge  of  the  bony  landmarks  and  the  mutual  re- 
lations of  the  soft  parts.  The  lecturer  is  therefore 
obliged  to  spend  a  little  time  at  least  in  describing  the 
bones,  muscles,  arteries  and  nerves  of  the  region,  the 
surgery  of  which  is  to  be  discussed.  The  carotid,  tem- 
poral and  facial  arteries  must  be  remembered,  because 
of  the  hemorrhage,  which  occurs  from  them  during 
operations,  and  because  the  bloodsupply  of  flaps  made 
in  plastic  operations  is  a  matter  of  supreme  importance. 
The  situation  of  the  branches  of  the  facial  nerve  and 
the  position  of  the  duct  of  the  parotid  gland  must  be 
always  in  the  mind  of  the  operator,  lest  wound  of 
these  important  structures  occur. 

The  upper  jaw  is  of  major  importance  in  the  con- 
struction of  the  face,  forming  as  it  does  portions  of  the 
walls  of  the  orbit,  nose  and  mouth.  Its  alveolar  arch 
must  correspond  with  the  same  portion  of  the  lower 
jaw,  in  such  a  way  that  the  upper  teeth  may  lie  in  front 
of  the  lower  jaw  when  the  mouth  is  closed.  The  in- 
cisive portions  of  the  two  upper  jaw  bones  are  devel- 
oped by  special  centers  of  ossification.  They  therefore 
have  much  to  do  with  the  shape  of  the  lower  portion 
of  the  face  and  mouth.  Harelip  and  cleft  palate 
are  the  most  conspicuous  and  most  common  con- 
genital deformities  due  to  improper  development  of 
this  portion  of  the  facial  skeleton.  Another  disfigure- 
ment is  that  in  which  the  lower  jaw  with  its  teeth 
project  in  front  of  the  upper  jaw.  This  deformity  is 
said  to  be  due  at  times  to  precocious  ossification  of  the 


sutures  between  the  body  of  the  upper  jaw  and  its  in- 
termaxillary or  incisive  portion.  As  a  result,  the  upper 
jaw  and  teeth  do  not  develop  in  a  forward  direction  as 
much  as  they  should  and  the  lower  jaw  gains  an  undue 
relative  prominence.  The  lower  segment  of  the  face  is 
therefore  altered  in  an  unseemly  manner.  Mechanical 
appliances  to  prevent  this  ugly  alteration  in  the  rela- 
tion of  the  two  jaws  may  be  successfully  employed  in 
young  children. 

The  lower  jaw  varies  greatly  in  shape  in  different  in- 
dividuals and  at  different  periods  of  life.  The  angle 
between  ramus  and  body  in  the  adult  male  is  about 
122°.  It  is  very  obtuse  in  infants,  and  more  obtuse  in 
women  than  in  men.  Changes  in  the  angle  of  the 
mandible  and  the  prominence  of  the  chin,  produced  by 
the  loss  of  teeth  and  the  absorption  of  the  alveolus  in 
old  age,  give  the  characteristic  appearance  of  the  senile 
face.  Ankylosis  of  the  temporo-maxillary  joints  pre- 
venting movement  of  the  lower  jaw  will,  if  occurring 
in  childhood,  lead  to  atrophy  or  want  of  proper  de- 
velopment. An  immature  chin  thus  results,  causing 
conspicuous  disfigurement  of  the  individual.  Burns  of 
the  lower  part  of  the  face  and  neck  in  early  life  often 
prevent  proper  mobility  of  the  lower  jaw  and  lead  to  a 
lengthening  and  bending  downward  of  the  bone.  Per- 
sistent thumbsucking  in  young  children  after  the 
second  dentition  causes  deviation  of  the  teeth  and  an 
abnormal  relation  of  the  jaw-bones. 

The  frontal  eminences  are  better  marked  in  young 
persons  and  women  than  in  adult  males,  because  in  the 
latter  the  greater  development  of  the  frontal  sinuses 
brings  the  lower  portion  of  the  frontal  bone  forward  in 
the  neighborhood  of  the  superciliary  ridges.  The  frontal 
sinus  begins  to  develop  at  about  seven  years  of  age. 

A  study  of  the  facial  angle  and  its  measurement  by 
the  goniometer  of  Camper  are  interesting  to  anatomists 
and  surgeons  as  well  as  to  artists. 

The  face  of  the  infant  is  small  in  comparison  with 
the  rest  of  the  head.  The  cranium  of  the  baby  is  five 
or  six  times  as  large  as  the  face.  The  development,  as 
the  infant  grows,  of  the  superciliary  arches  and  frontal 
sinuses  makes  the  frontal  eminences  less  conspicuous, 
and  the  forehead  therefore  assumes  a  more  receding 


character.  The  face  at  first  is  short  in  comparison  with 
its  breadth  and  lacks  the  prominence  of  the  adult  face. 
This  is  largely  due  to  the  absence  of  teeth.  The 
growth  of  the  jaws,  which  occurs  when  the  teeth  have 
erupted,  changes  the  lower  portion  of  the  face  into  that 
of  the  adult. 

The  appearance  of  the  human  face  has  varying  char- 
acteristics in  different  races  of  men  and  in  different  in- 
dividuals of  the  same  race.  A  protruding  face  is  called 
prognathous ;  the  nonprotruding  face,  orthognathous ; 
and  a  broad  face  eurygnathous.  The  Caucasian  face  is 
orthognathous  and  often  prominent  mesially  and  cen- 
trally, while  the  African  and  Mongolian  races  have  prog- 
nathous faces.  The  Mongolians  have  faces  which  are 
broad  and  centrally  depressed  as  well  as  prognathous. 

The  muscular  structures  of  the  face  differ  from  the 
muscles  of  the  extremities  in  that  one  end  of  many 


Crude  diagrams  showiDg  change  in   expression  caused  by  change  in  shape  of 

mouth. 

of  the  muscles  is  inserted  into  the  skin,  which 
is  movable  and  drawn  into  folds  and  wrinkles 
at  right  ankles  to  the  direction  of  the  muscular 
pull.  In  subjects  whose  skin  is  thin  and  flexible 
muscular  contraction  causes  many  and  delicate  wrin- 
kles. When  the  skin  is  thick  and  stiff  by  nature 
or  as  the  result  of  disease,  a  slight  action  of  the  muscles 
of  expression  will  produce  no  visible  wrinkling.  More 
active  contraction  will  cause  few  and  thick  wrinkles. 
Under  the  latter  circumstances  delicate  shades,  and 
variety  and  beauty,  of  facial  expression  are  absent. 

There  are  two  main  muscular  landmarks  on  the 
front  of  the  face.  One  about  the  two  eyes  and  one 
around  the  mouth.  They  are  in  a  certain  sense  sphinc- 
ter muscles,  closing  the  eyelids  and  the  opening  of  the 


mouth.  The  orbicular  muscle  of  the  mouth  has  its 
fixed  attachments  in  the  middle  line  above  and  below, 
but  the  orbicular  muscles  of  the  eyelids  have  their  fixed 
points  at  the  outer  and  inner  ends.  Many  of  the 
muscles  of  expression  are  inserted  into  or  blend  with 
the  fibers  of  the  orbicular  muscle  of  the  mouth  and  by 


Action  ot  corrugators  of  eyebrow  shown  in  expression  of  suftering. 

acting  upon  it  make  great  changes  in  the  expression  ot 
the  face. 

The  mobility  of  the  lips,  the  bulk  of  which  is  chiefly 
the  orbicular  muscle,  gives  expression  to  the  face  to  a 
much  greater  extent  than  any  muscular  movement 
about  the  evelids  and  forehead. 


The  muscles  of  the  face  occur  in  pairs.  The  frontal 
muscle  and  orbicular  muscle  of  the  mouth,  though  each 
is  spoken  of  as  single,  are  really  two  lateral  muscles 
usually  acting  as  one. 

The  action  of  the  frontal  muscle  is  to  raise  the  eye- 
brows and  make  transverse  wrinkles  in  the  skin  of  the 
forehead.     It  has  been  called  the  muscle  of  attention. 


The  nasolabial  line  and  the  transverse  furrows  of  the  forehead  are  well  shown 
in  this  photograph. 

When  acting  excessively  it  produces  the  appearance  of 
astonishment. 

The  corrugator  muscles  of  the  eyebrows  pull  the  eye- 
brows inward  and  downward  near  their  nasal  ends, 
making  vertical  wrinkles  between  the  eyebrows  above 
the  root  of  the  nose.  This  expresses  frowning  shown 
in  mental  and  physical  suffering.     The  greater  zygo- 


matic  muscles  draw  upward  the  angles  of  the  mouth 
and  cause  wrinkles  under  the  eyes,  thus  giving  rise  to 
the  expression  of  joy.  They  are  assisted  by  the  elevators 
of  the  angle  of  the  mouth. 

A  well  marked  furrow  in  the  face  is  the  nasolabial 
line  extending  downward  and  outward  from  the  wing 
of  the  nose  to  a  point  external  to  the  angle  of  the 
mouth.  It  is  seen  in  all  faces,  especially  in  the  aged. 
The  nasolabial  line  changes  its  shape  with  the  action  of 
various  muscles  of  emotion.  It  is  important  to  the 
surgeon,  because  incisions  made  along  its  groove  show 
little  scar.  In  laughter  the  nasolabial  line  assumes  a 
double  curve  like  the  old  italic  S.  In  pain  it  is 
straight;  in  grief,  convex  outward.  In  contempt  it  is 
drawn  in  at  the  lower  end  and  extended  around  the 
anofle  of  the  mouth. 


Crude  diagrams  showing  cliaoge  of  expression  caused  by  changes  in  the  naso- 
labial lines. 

Other  emotions  are  shown  by  similar  actions  and 
combinations  of  action  of  the  small  muscles  of  the  face, 
which  are  inserted  into  the  skin  or  into  the  muscular 
mass  of  the  lips. 

In  true  emotions  the  muscles  of  the  various  portions 
of  the  face  act  in  consonance  involuntarily  and  produce 
expressions  which  seem  to  us  natural.  We  can,  how- 
■ever,  by  distinct  voluntary  effort  bring  disassociated 
muscles  into  action,  and  thereby  produce  a  grimace. 
It  is  interesting  to  observe  how  the  anatomic  situation 
and  nervous  supply  of  muscles  indicate  what  emotions 
can  occur  together.  This  anatomic  basis  of  expression 
<;orresponds  exactly  with  the  psychic  relations  of  the 
phenomena.     It  is   impossible,   for   example,  to   give 


10 

attention  to  external  objects  and  to  be  at  the  same  time 
in  a  state  of  meditation.  The  impossibility  of  such  a 
mental  contradiction  is  anatomically  shown  in  the  fact 
that  the  frontal  muscle  cannot  carry  the  eyebrow  up- 
ward to  indicate  attention  while  the  orbicular  muscle 
of  the  eyelids  is  pulling  it  down  to  indicate  meditation. 

Lecture  III. — Characteristics    of  Surgery  in   the   Face. 
— The  Principles  of  Plastic  Surgery  of  the  Face. 

[Abstract.] 

The  skin  of  the  face  is  thin,  elastic,  and  very  vascular. 
Its  vascularity  and  elasticity  render  it  suitable  for 
jslastic  procedures.  Incision  should  be  made  in  posi- 
tions where  there  is  usually  a  shadow,  as  under  the 
eyebrow  or  beneath  the  lower  jaw,  or  in  the  bottom  of 
the  furrows  produced  by  the  habitual  expressions  of  the 
patient.  When  these  positions  cannot  be  chosen  the 
surgeon's  cut  should  be  made  parallel  to  the  facial  lines 
rather  than  across  them.  A  slightly  curved  line  makes 
a  less  conspicuous  scar  than  a  straight  or  abruptly 
curved  one.  Accurate  apposition  should  be  made  by 
means  of  sutures.  Oblique  incisions  through  the  skin 
permit  more  accurate  apposition  than  those  dividing 
the  skin  in  a  plane  at  right  angles  to  the  surface.  The 
intracuticular  suture  is  sometimes  valuable  ;  but  is  not 
necessary,  if  thin  silk  is  employed  and  the  wound  kept 
aseptic.  Formaldehyd  catgut  may  be  used  instead  of 
silk,  because  it  may  be  thin  without  being  absorbable  as 
soon  as  the  ordinary  catgut  suture.  The  infrequency 
of  valves  in  the  veins  of  the  face  is  said  to  be  the  cause 
of  the  rapid  spread  of  septic  inflammations  in  this 
region.  Wounds  should  therefore  be  kept  free  from 
contamination.  The  bones  of  the  face  have  a  good 
blood-supply,  and  many  of  them  are  comparatively 
soft.  They  may  be  utilized  for  plastic  operations  with- 
out much  danger  of  necrosis. 

Portions  of  the  nose,  ear  or  lip  which  have  been  cut 
off  should  be  readjusted  and  sutured  in  position,  for 
there  is  a  fair  prospect  of  immediate  union  of  such 
parts  accidentally  separated  from  the  face. 

It  is  better  as  a  rule  to  keep  the  wounds  dry.  They 
may  be  covered  with  a  small  piece  of  aseptic  gauze,  or 


11 

an  aseptic  scab  may  be  formed  by  dusting  a  little  boric- 
acid  powder  over  the  wounds  and  allowing  it  to  form  a 
crust  with  the  serum. 

Incisions  in  the  cheek  should,  Avhen  possible,  avoid 
perforating  the  mucous  membrane.  This  prevents 
infection  from  the  bacteria  within  the  mouth.  Drainage, 
when  necessary,  should  be  into  the  mouth  and  not  upon 
the  surface  of  the  face.  The  duct  of  the  parotid  gland 
must  be  avoided.  If  cut,  the  proximal  end  should 
be  carried  iato  the  mouth  through  a  properly  placed 
incision.    This  avoids  the  occurrence  of  external  fistula. 

Plastic  surgery  is  called  into  requisition  to  repair 
congenital  malformations  and  deformities,  the  result  of 
injury  or  disease. 

Displacement  of  skin  by  stretching  or  sliding,  trans- 
ferring a  flap  with  a  pedicle,  and  transplanting  por- 
tions of  tissue  from  the  face  or  other  regions,  without 
pedicles,  are  the  chief  methods  employed.  Occasion- 
ally the  flap  to  be  used  for  repairing  a  gap  is  not  put 
into  position  until  inflammatory  changes  have  in- 
creased its  vascularity  and  thickness. 

Plastic  surgery  may  also  have  for  its  object  the  cur- 
tailing of  abnormally  large  organs,  such  as  noses,  ears 
and  lips. 

Plastic  surgery  should  not  be  done  upon  a  patient  in 
poor  health  nor  when  septic  contamination  is  particu- 
larly likely  to  occur.  Syphilitic  processes  should  be 
stopped  by  treatment  before  the  deformities  caused  by 
them  are  corrected  by  operation. 

A  series  of  operations  may  be  necessary  to  obtain 
the  best  cosmetic  result.  A  bulky  resemblance  to  the 
organ  to  be  constructed  is  made  first.  Subsequent 
improvement  is  then  obtained  by  minor  operations, 
with  suflicient  intervals  between  them  to  permit  the 
absorption  of  inflammatory  exudate  and  cicatricial 
shrinking. 

Flaps  may  be  jumped  across  a  bridge  of  skin,  may 
be  turned  upside  down  and  skin-grafted  upon  the  raw 
surface,  or  one  flap  may  be  put  upon  the  top  of 
another  to  raise  depressed  portions  of  the  face.  Flaps 
containing  periosteum  and  bone  are  sometimes  used. 
Plastic  flaps  should  contain  a  good  deal  of  subcutaneous 
tissue,  and  should  have  a  wide  pedicle  when  possible. 


12 

The  flaps  should  be  about  one-third  larger  than  the 
space  to  be  filled  in. 

In  transplanting  portions  of  skin  without  pedicles 
the  best  results  are  usually  obtained  by  removing  the 
subcutaneous  fatty  tissue,  and  keeping  the  wound 
absolutely  dry  and  free  from  antisej^tic  solutions. 
Asepsis,  not  antisepsis,  is  an  essential  here. 

If  gangrene  occurs  it  is  wise  not  to  remove  hastily 
the  tissue  which  seems  to  have  lost  its  vitality.  Very 
often  only  the  surface  or  the  edges  will  actually  die, 
and  a  much  better  result  will  be  obtained  than  the 
surgeon  expects  when  he  sees  the  tissue  beginning  to 
slough. 

Lecture  IV. —  The  Removal  of  Disfigurements  Due  to 
Pigments,  Cicatricial  Distortions,  Errors  of  Develop- 
ment, Tumors  and  Skin  Diseases. 

[Abstract.! 

Unburxt  powder  imbedded  in  the  skin  and  subcu- 
taneous tissue  and  intentional  tattooing  with  black 
pigments  cause  blue  stains  in  the  skin.  Coal  miners 
often  suffer  similar  disfigurements  from  wounds  being 
soiled  with  coal  dust.  Wounds  soiled  with  gunpowder 
or  coal  dust  must  be  at  once  thoroughly  scrubbed  with 
soap  and  lot  water  and  a  brush,  to  remove  the  particles 
of  carbon.  Anesthesia,  local  or  general,  may  be  needed 
for  such  treatment.  When  the  skin  has  healed  over  the 
imbedded  carbon,  the  discoloration  can  only  be  re- 
moved by  excising  the  stained  area  or  tediously  remov- 
ing each  particle.  Croton  oil  has  been  picked  into  the 
skin  to  cause  suppuration  and  extrusion  of  the  black 
particles.  Combustive  destruction  of  the  carbon  by 
introducing  a  red  hot  galvanocaustic  needle  has  been 
proposed.  Dermatologists  employ  chemical  means  to 
remove  intentional  tattooing.  The  discolorations  due 
to  accidental  wounds  are  probably  too  deep  for  success 
by  this  method. 

Glycerole  of  papain  has  been  picked  deeply  into  the 
skin  with  the  object  of  removing  the  pigment  after 
tattooing.  Another  method  sometimes  employed  is  to 
pick  into  the  skin  a  solution  of  tannic  acid.  A  stick  of 
silver  nitrate  is  then  firmly  rubbed  into  the  punctured 


13 

area.  Silver  tannate  is  formed  where  the  tannin  has 
been  picked  into  the  skin.  Of  course,  scabs  form  and, 
on  removing  the  scabs  in  about  two  weeks,  it  is  found 
that  the  pigmentary  stain  is  gone. 

Cicatricial  distortions,  unimportant  in  other  regions, 
are  unsightly  upon  the  face.  Operations  producing 
distorted  scars  should  be  avoided,  if  possible.  Syphil- 
itic ulcers  should  be  treated  early  and  vigorously. 
Abscesses  may  be  opened  on  the  mucous  surface  of  the 
cheek.  Tuberculous  glands  may  be  removed  or  drained 
before  they  by  spontaneous  opening  cause  ugly  scars. 

Tumors  should  be  excised  by  incisions  so  placed  as 
to  prevent  cicatricial  distortion  of  the  eyelids,  mouth 
and  nose.  Plastic  operations  to  fill  the  gap  left  by  re- 
moval of  the  tumor  will  often  be  necessary. 

Burns  make  extensive  and  horrid  deformities  of  the 
face.  Keloid  degeneration  of  scars  is  a  cause  of  disfig- 
urement in  many  scars  otherwise  unimportant.  The 
disease  occurs  more  frequently  in  the  black  race  than 
in  the  white.  It  may  attack  leech  bites,  acne  pustules, 
smallpox  scars  and  even  fly  blisters,  as  well  as  ordinary 
wounds.  The  keloid  growth  may  return  after  excision. 
It  is  a  disease  of  youth  and  adolescence,  and  usually 
disappears  spontaneously  before  middle  life.  Extract 
of  thyroid  gland  internally  and  local  applications  of 
collodion  have  been  used  by  White  in  hypertrophy  of 
scar  tissue  resembling  keloid  disease.  Excision,  if 
employed,  should  be  made  at  a  considerable  distance 
from  the  boundaries  of  the  keloid  mass. 

The  unsightliness  of  depressed  or  irregular  scars  may 
be  lessened  by  excision  and  by  transference  or  trans- 
plantation of  skin.  Moderately  depressed  scars  may 
be  treated  by  rubbing  the  skin  with  finely  powdered 
calcium  carbonate.  This  attrition  removes  or  prevents 
the  epithelial  accumulation  along  the  edges,  which 
makes  the  depression  more  conspicuous.  The  pits  of 
smallpox  may  be  thus  treated  with  some  success.  The 
white  spots  of  vitiligo  may  be  made  less  conspicuous 
by  removing  the  excess  of  pigment  which  usually  ap- 
pears at  the  margin  of  the  white  spots.  This  is  to  be 
done  by  applications  similar  to  those  used  in  the  re- 
moval of  freckles.  Corrosive  sublimate,  three  or  five 
grains  to  the  ounce,  is  a  good  application. 


14 

Congenital  fistules  and  fissures  occur  from  imperfect 
closure  of  the  branchial  clefts.  They  are  usually  best 
treated  by  excision.  Fistules  due  to  suppurative  dis- 
ease of  the  accessory  sinuses  of  the  nose  are  difficult 
to  close  because  of  the  trouble  in  thoroughly  sterilizing 
the  mucous-lined  cavities  from  which  they  arise.  Drain- 
age and  disinfection  are  important  parts  of  the  treat- 
ment. 

Meningocele  and  encephalocele  cause  tumors  upon 


Case  of  distigiireraent  from  burns.  Improved  by  incising  scar-tissue  under 
chin  and  taking  two  long  flaps  from  back,  which  were  brought  around  the 
front  of  the  neck  like  a  cravat. 

the  face  which  should  be  treated  by  aseptic  excision. 
Deficiency  and  atrophy  of  the  bones  ot  the  face  are 
curious  conditions  due  to  irregularities  in  development 
and  nutrition.  Osteoplastic  operations  may  under 
some  circumstances  be  valuable.  Prosthetic  appliances 
of  wax,  papier  mache  or  celluloid  are  occasionally  of 
service  in  concealing  excessive  deformity  due  to  these 
cause'. 


15 

Facial  hemiatrophy  is  another  disfiguring  condition 
due  to  a  trophoneurosis  occurring  not  only  in  children, 
but  also  in  adults.  Hypertrophy  of  the  bones  of  the 
face  occurs,  giving  a  leonine  appearance  to  the  patient. 


Case  of  hemiatrophy  of  the  face,  with  small  abscess  communicating  with  one  oi 
the  accessory  sinuses  of  the  nose  on  the  same  side  as  the  atrophy. 


The  bulky  bone  may  be  reduced  by  chiseling  opera- 
tions. 

Many  skin  diseases  are  most  disfiguring  when  oc- 
curring upon  the  face.     A  large  number  of  them  are 


16 


readily  removed  by  judicious  treatment  directed  to  the 
general  health  of  the  patient  and  accompanied  by 
proper  local  remedies  to  alter  the  nutrition  of  the  skin. 

Comedo,  sebaceous  cyst,  and  various  forms  of  acne 
are  characteristic  dermal  affections,  which  need  a  com- 
bination of  general  and  local  treatment.  Surgical  man- 
agement is  sometimes  required. 

Warts,  horns  and  moles  are  occasionally  allowed  to 
become  a  source  of  great  perturbation  to  the  patient's 
mind,   and   need  mechanical   treatment.      Congenital 


Case  of  dennatolysis  treated  successfully  by  excision  followed  by  application  of 
flaps  from  the  arm,  neck  and  forehead  and  by  skin-grafting. 


moles  are  often  large,  pigmented  and  hairy.  Such 
growths  require  extensive  surgical  operations  for  their 
removal.  Hairy  growths  are  best  removed  by  electro- 
lysis. The  method  is  a  slow  one,  but  is  effectual ;  if  the 
electrolytic  needle  at  the  negative  pole  is  inserted  with 
care  into  the  hair-follicles.  It  has  been  proposed  to 
graft  shavings  of  skin,  taken  after  the  method  of 
Thiersch,  upon  the  surface  left  after  shaving  off  the 
pigmented  tissue  which  forms  the  bulk  of  the  mole. 

Vascular  tumors  and  discolorations  may  be  treated 
by  extirpation  with  a  knife  and  in  some  cases  by  elec- 


17 

trolysis.  When  possible,  excision  is  most  expeditious 
and  radical.  If  well  done,  it  leaves  little  scar  to  cause 
disfigurement. 

A  circumscribed  hypertrophy  of  the  skin,  called 
dermatolysis,  in  which  soft  masses  of  thickened  integu- 
ment hang  in  loose  folds  over  the  face,  is  of  occasional 
occurrence  in  the  face.  It  is  to  be  treated  by  excision, 
skin-grafting  and  the  transference  of  cutaneous  flaps. 

Lupus,  which  is  a  cutaneous  tuberculosis,  causes 
great  ravages  to  the  skin.  It  produces  ectropion  of  the 
eyelids  and  lips,  a  shrunken,  beak-like  nose  or  even 
complete  destruction  of  the  external  nose,  contraction 
of  the  opening  of  the  mouth,  and  distortion  of  the  lips 
and  ears.  The  disease  should  be  removed  by  dissec- 
tion and  covering  the  space  with  skin-shavings,  by 
scraping  the  diseased  structures  away  with  the  curet, 
or  by  using  strong  caustics.  The  use  of  tuberculin  was 
supposed  to  be  beneficial.  A  more  prolonged  experi- 
ence with  the  remedy  has,  however,  not  proved  its 
claims  to  be  wholly  substantiated. 

Lecture  V. — Deformities  of  the  Lips  and  Mouth. 

[Abstract.] 

The  chief  congenital  deformity  of  the  mouth  is  hare- 
lip, which  with  its  complications  gives  ample  oppor- 
tunity for  the  exercise  of  constructive  skill.  Other 
congenital  defects  are  atresia  oris,  macrostoma,  micro- 
stoma, cleft  of  the  lower  lip,  hypertrophy  of  the  lips, 
and  excessive  eversion  of  the  lower  lip.  Distortion  of 
the  mouth  and  lips  and  deficiencies  of  the  lips  and 
cheeks  occur  as  the  result  of  sloughing  and  injuries. 

The  treatment  of  congenital  occlusion  of  the  mouth 
and  of  cicatricial  contraction  consists,  in  the  former  case, 
in  dividing  the  occluding  membrane  and  preventing 
readhesion  of  the  lips,  and,  in  the  latter  case,  in  mak- 
ing horizontal  incisions  outward  from  the  orifice  repre- 
senting the  mouth.  The  mucous  membrane  must  be 
sutured  into  the  end  of  the  incision  to  prevent  reunion 
of  the  edges  of  the  wound.  Occasionally  a  V-shaped 
piece  of  cheek  must  be  removed  with  the  point  of  the 
V  extending  outwards. 

Imperfect  closure  of  the  branchial  clefts  may  cause  a 


18 

congenital  horizontal  fissure  at  one  or  both  sides  of  the 
mouth,  extending  outward  into  the  cheek  and  causing 
the  condition  termed  macrostoma.  This  deformity  is 
treated  by  freshening  the  edges  and  applying  sutures. 
Similar  deficiencies  in  closure  of  fetal  structures  cause 
fissures  in  the  upper  lip,  termed  harelip,  and  occasion- 
ally in  the  lower  lip.  In  rare  instances  these  fissures 
may  extend  up  as  far  as  the  orbit  or  down  to  the  ster- 
num. Sometimes  a  mere  cicatricial  line  is  seen  in  the 
child's  lip,  as  though  an  intrauterine  cure  of  such  a 
fissure  had  taken  place.  The  treatment  of  all  these  fis- 
sures is  based  on  the  same  general  operative  procedure 
as  that  just  described  for  macrostoma. 

The  lips  may  be  enlarged  from  interstitial  increase  of 
all  the  structures,  from  lymphedema,  from  chronic  in- 
flammation and  from  the  presence  of  tumors.  Chil- 
dren, the  subjects  of  cretinism,  tuberculosis  or  in- 
herited syphilis,  sometimes  have  enlarged  lips.  Gen- 
eral treatment  directed  to  the  cause  of  the  trouble  will 
usually  ameliorate  or  remove  the  deformity.  Thyroid 
extract  is  suggested  in  cretinoid  cases.  A  hypertrophied 
lower  lip  may  be  altered  by  excision  of  a  V-shaped 
piece  in  the  middle  line  with  the  apex  of  the  V  near 
the  chin.  This  lessens  the  width  of  the  lip.  Its  thickness 
may  require  a  second  operation  to  remove  a  wedge  of 
tissue  by  incisions  running  across  the  free  border  of  the 
lip.  Eversion  of  the  lips,  giving  rise  to  what  is  some- 
times called  double  lip,  is  to  be  treated  by  excision  of 
a  section  of  the  lip  by  means  of  transverse  incisions 
along  the  mucous  surface. 

Eversion  of  the  lip,  due  to  burns  of  the  chin  and 
neck,  must  be  corrected  by  sliding  upward  a  V-shaped 
flap  from  the  throat  or  chest,  transferring  a  flap  with  a 
pedicle  from  the  side  of  the  neck,  or  transplanting  a 
piece  of  skin  without  a  pedicle  from  some  other  part  of 
the  body.  Occasionally  it  will  be  found  desirable  to 
employ  the  method  of  Tagliacozzi  and  use  the  arm  for 
supplying  the  flap.  I  have  recently,  in  a  case  of  everted 
lip  from  burn,  in  which  there  was  also  a  cicatricial 
deformity  of  the  hand,  used  the  hand  for  carrying  a 
portion  of  the  abdominal  skin  to  the  chin.  This  was 
done  by  first  grafting  a  flap  of  skin  from  the  abdomen 
to  the  back  of  the  hand  where  the  cicatrix  had  been 


19 

freed  by  incisions.  After  adhesion  had  taken  place, 
the  flap  was  cut  loose  from  the  belly  and  the  hand 
applied  to  the  face,  so  that  a  portion  of  the  abdominal ' 
skin  could  be  sutured  to  the  raw  surface  made  upon 
the  chin,  by  dissecting  loose  the  scar-tissue  in  the  lower 
lip.  Gypsum  bandages  held  the  arm  in  position  until 
the  graft  had  become  attached,  when  the  hand  was 
cut  loose.  This  method  of  using  the  hand  for  trans- 
ferring tissue  is  a  valuable  one,  originally  suggested,  I 
believe,  by  Shrady. 

When  the  cheek  is  distorted  by  operation  or  by  in- 
jury, a  U-shaped  flap  may  be  turned  up  from  the  neck 
and  thrust  through  a  buttonhole  incision  made  along 
the  lower  margin  of  the  jaw,  so  that  the  skin-surface  is 
turned  toward  the  teeth.  This  operation  is  only  satis- 
factory when  there  is  not  much  beard  upon  the  skin 
turned  inward. 

Deformities  of  the  lower  part  of  the  face  arise  after 
excision  of  the  mandible  for  necrosis  or  tumor,  because 
the  muscles  displace  the  portion  of  the  lower  jaw  which 
is  retained.  This  displacement  may  be  largely  pre- 
vented ;  by  having  a  dentist  cap  the  teeth  and  anchor 
the  fragment  of  the  lower  jaw  to  the  teeth  of  the  upper 
jaw,  or  in  some  similar  manner  arranging  a  spring 
within  the  mouth  to  hold  the  normal  portion  of  the 
jaw  in  proper  position.  An  artificial  appliance  may 
subsequently  be  made  to  represent  the  removed  bone, 
and  a  vulcanite  cheek-plumper  may  be  adapted  to  fill 
out  the  collapsed  cheek. 

The  obliquity  of  the  mouth  due  to  facial  paralysis 
may  be  improved  by  excising  an  elliptical  portion  of 
tissue  from  the  cheek.  Dental  irregularities  and  mal- 
formations and  discolored  teeth  require  skilful  work 
of  a  trained  dentist.  This  branch  of  surgery  has  been 
greatly  developed  in  recent  years.  Contracted  jaws, 
irregular  eruption  of  teeth,  and  abnormal  relation 
in  the  projection  of  the  upper  and  lower  jaws  may  be 
corrected,  it  proper  appliances  are  adopted. 

Much  harm  is  done  by  the  erroneous  extraction  of 
teeth,  in  the  endeavor  to  make  room  for  the  eruption  of 
other  teeth.  The  canines  should  seldom  if  ever  be  ex- 
tracted for  this  purpose,  because  they  have  much  to  do 
with  the  shape  of  the  face.     Careful  study  of  the  physi- 


20 

ology  of  dentition  is  required  before  deciding  which  is 
the  proper  tooth  to  extract.  Prominence  of  the  lower 
jaw,  causing  prognathism,  may  be  greatly  improved  by 
a  net  cap  worn  at  night  with  proper  rubber  bands  at- 
tached to  a  jaw  support.  A  change  in  the  bite,  or  ar- 
ticulation of  the  teeth,  may  often  be  made,  by  means  of 
which  the  improper  relation  between  the  upper  and 
lower  jaw  may  be  gradually  corrected.  The  success  of 
such  corrective  measures  is  greater  and  more  promptly 
obtained  in  adolescents  than  in  adults.  It  is  probable 
that  between  the  ages  of  12  and  20  is  the  best  period ; 
but  even  up  to  30  years  of  age  much  can  be  done  by 
patient,  judicious  mechanical  treatment. 

Where  the  lower  jaw  is  greatly  deformed  by  drag- 
ging down  of  the  lower  lip  from  cicatricial  contrac- 
tion, a  section  removed  from  both  sides  of  the  jaw  may 
enable  the  surgeon  to  bring  the  chin  and  the  lower 
teeth  into  proper  relation  to  the  rest  of  the  face.  These 
cases  require  careful  study  and  aseptic  operative  treat- 
ment. 

I  have  at  the  present  time  under  consideration  a  case 
of  relatively  retracted  chin ;  on  which  it  is  possible  I 
may  operate  to  bring  forward  the  chin,  by  detachment 
and  displacement  of  the  mental  tubercle  and  the  graft- 
ing of  bone  taken  from  the  tibia. 

Lecture  VI.- — The  Reconstruction  of  the  Lips  and  Cheeks. 

(Abstract.) 

Congenital  fissure  of  the  upper  lip,  usually  called 
harelip,  is  one  of  the  most  common  deformities  requir- 
ing reconstructive  operations  about  the  mouth.  Labial 
fissure  also  occurs  in  the  lower  lip,  but  not  as  commonly 
as  in  the  upper.  In  the  lower  lip,  the  fissure  is  usually 
in  the  middle  line.  In  the  upper  lip,  it  is  more  com- 
mon to  have  it  at  one  side  of  the  middle  line.  These 
deformities  are  due  to  imperfect  coalescence  of  the 
branchial  arches  during  fetal  life.  Eeconstructive  op- 
erations are  also  required  after  removal  of  malignant, 
tumors  of  the  lips  and  cheeks,  and  to  overcome  de- 
formities the  result  of  cicatricial  contraction,  particu- 
larly from  burns  of  the  face. 

Harelip  may  be  unilateral  or  bilateral.     It  may  be- 


21 

complicated  with  cleft  of  the  alveolar  process  of  the 
jaw,  cleft  of  the  entire  palate,  or  with  protrusion  of 
the  entire  intermaxillary  bone,  in  addition  to  palatal 
cleft.  The  intermaxillary  bone  is  sometimes  displaced 
and  attached,  as  it  were,  to  the  point  of  the  nose,  giving 
the  child  a  snout-like  deformity  of  the  upper  lip  and 
nose. 

The  various  forms  of  labial  fissure  are  treated  by 
freshening  the  edges  of  the  cleft,  replacing  protruding 
portions  of  the  intermaxillary  bone,  and  suturing  the  soft 
parts  alone,  or  the  soft  parts  and  the  replaced  bony  tis- 
sues. The  operation  should,  as  a  rule,  be  done  before  the 
third  month  of  the  child's  life,  unless  the  child  is  sickly 
or  the  operation  is  going  to  be  a  bloody  one  because 
of  the  complicated  nature  of  the  case.  An  early  closure 
of  the  lip  seems  to  aid  in  causing  a  tendency  for  an 
accompanying  palatal  fissure  to  become  less  as  the  child 
grows  up.  Anesthesia  should  always  be  employed.  To 
operate  without  anesthesia  is  a  cruel  practice. 

Complicated  harelips  may  be  left  until  about  the  sec- 
ond year,  if  the  child's  health  is  bad  or  the  dagger  of 
hemorrhage  producing  ill  effects  great.  The  methods 
of  bringing  the  parts  into  apposition  vary  greatly  with 
different  operators,  but  the  principles  are  simple  enough. 
The  edge  of  the  cleft  should  be  pared  in  such  a  way  as 
to  give  a  broad  surface  of  contact,  and  to  make  that  side 
of  the  lip,  which  is  the  shorter,  long  enough  to  make 
the  lip  have  the  proper  shape.  To  prevent  the  forma- 
tion of  a  notch  at  the  vermilion  border,  the  incisions 
should  be  so  placed  as  to  give  plenty  of  tissue  at  the  free 
margin  of  the  lip.  Suturing  should  be  done  so  care- 
fully that  the  mucous  membrane  does  not  show  upon 
one  side  at  a  higher  point  than  the  other. 

The  length  of  the  lip  from  the  nose  to  the  orifice  of 
the  mouth  should  be  made  sufficiently  great.  Surgeons 
often  neglect  this  important  point.  The  flattened  nostril 
should  be  altered  by  changing  the  position  of  the  wing  of 
the  nose.  This  can  often  be  done  by  an  incision  outside 
of  the  wing  of  the  nose  in  the  curve  between  it  and  the 
cheek.  It  may  be  necessary  to  saw  the  alveolar  process 
and  bring  a  portion  of  that  bony  structure  toward  the 
middle  line,  in  order  to  make  a  floor  for  the  wing  of  the 
nose  to  rest  upon.  This  is  easily  done  before  closure  of 
the  lip. 


22 

Trusses  to  press  the  cheek  inward  toward  the  middle 
line,  metal  supports  to  the  lip,  harelip  pins  and  similar 
devices  are  to  be  discarded.  Properly  placed  incisions 
with  sutures  of  silk,  silkwormgut  or  formaldehyde  catgut 
are  all  that  is  necessary. 

The  intermaxillary  bone,  if  thrust  forward,  should  be 
bent  backward,  after  fracturing  the  cartilage  and  bone^ 
or  excised.  It  is  sometimes  necessary  to  cut  out  a  V- 
shaped  portion  of  the  septum  of  the  nose  before  pushing 
backward  the  projecting  intermaxillary  bone.    The  soft 


Double  harelip  with  protrusion  of  iatermaxillary  bone. 


tissues  over  the  intermaxillary  bone  may  be  used  to  con- 
struct the  columella  of  the  nose  or  to  aid  in  making  the 
central  portion  of  the  lip. 

Very  little  dressing  is  required  after  the  operation. 
Gauze  and  collodion,  dry  gauze,  or  a  little  boric  acid 
powder  may  be  used.  Adhesive  strips  are  a  disad- 
vantage because  they  are  liable  to  lead  to  septic  con- 
tamination. 

It  is  occasionally  necessary  to  make  long  incisions 


23 

outwards  into  the  cheeks  to  get  sufficient  tissue  to  dis- 
place towards  the  middle  line.  In  cases  when  there  has 
been  very  little  tissue  to  repair  a  double  harelip,  the 
patient  has,  even  after  a  well-performed  operation,  a 
very  taut  and  drawn  upper  lip,  which  contrasts  badly 
with  the  full  and  prominent  lower  lip.  A  V-shaped  por- 
tion of  the  lower  lip  should  then  be  removed,  in  order 
to  make  the  balance  between  the  two  lips  more  nearly 
like  that  in  a  normal  patient. 

It  is  sometimes  necessary  to  improve  the  appearance 
of  the  lip,  in  harelip  cases,  by  minor  operations  after 
the  child  grows  up  to  adolescent  life. 

Reconstructions  of  the  lower  lip  are  necessary  at 
times,  even  if  it  is  impossible  to  restore  the  expression 
and  beauty  of  the  mouth  in  anything  like  a  perfect 
manner.  The  operation  is  desirable  because  it  will 
prevent  the  escape  of  saliva  and  mucus,  improve  speech, 
enable  the  patient  to  keep  the  tongue  within  the  mouth, 
permit  drinking  and  taking  of  food,  and  lessen  the  in- 
terference with  digestion  which  is  apt  to  result  from 
imperfect  mastication  and  insalivation.  Even  if  the 
expression  of  the  face,  after  the  lips  and  cheeks  have 
been  restored,  is  imperfect ;  and  even  if  the  newly  con- 
structed part  is  absolutely  immobile,  the  operation 
makes  the  patient  less  ugly  and  makes  him  more  will- 
ing to  mix  in  the  society  of  his  fellows. 

It  is  difficult  to  give  definite  directions  for  cheiloplas- 
tic  procedures,  because  the  surgeon  must  be  governed 
by  the  peculiarities  of  the  case  under  observation. 
Almost  every  time  one  operates  the  method  must  be 
varied  to  meet  the  requirements.  Often,  indeed,  the 
necessities  of  the  case  determine  the  lines  of  incision 
only  after  the  operation  has  been  commenced. 

Pancoast  said  in  1843  that  there  is  scarcely  any  loss 
of  substance,  however  hideous,  of  the  mouth  and  lips, 
which  cannot  be  remedied  by  the  skill  and  ingenuity  of 
modern  surgeons.  This  statement  is  even  more  true 
today  than  it  was  fi  fty  years  ago. 

The  tissues  of  the  cheeks  are  usually  so  mobile  that 
unless  the  cicatricial  deformity  involves  them,  they  can 
be  displaced  by  proper  incisions  so  as  to  construct  an 
upper  or  lower  lip.  The  structures  beneath  the  chin 
and  of  the  neck  are  also  used  for  making  lower  lips. 


24 

A  large  flap  from  the  chin  with  the  pedicle  towards 
the  angle  of  the  jaw  may  be  turned  upwards  to  make  a 
lower  lip.  If  necessary,  a  portion  of  the  lower  jaw 
forming  the  chin  may  be  cut  away  to  lessen  the  tension 
on  a  flap.  A  bridge-shaped  flap  dissected  from  the 
region  below  the  chin  may  be  lifted  up  over  the  chin 
and  put  in  the  place  of  the  removed  lower  lip.  It  has 
been  suggested  to  take  a  strip  of  the  periosteum  from 
the  jaw  in  such  a  flap,  in  order  to  give  it  a  little  more 
rigidity.  This  rigidity  is  to  take  the  place  of  muscular 
tissue  in  the  flap. 

Both  lips  may  perhaps  be  made  by  taking  a  large 
flap  from  the  front  of  the  neck  near  the  hyoid  bone, 
with  pedicles  at  each  side  of  the  neck,  and  carrying  it 
like  a  bridge  above  the  chin  and  fastening  it  below  the 
nose.  A  slit  may  then  be  made  in  it  to  represent  the 
mouth. 


A.  Shows  lines  of  ircisions  for  one  method  of  cheiloplasty. 
sutured  in  position. 


B.  Shows  flaps 


A  good  lower  lip  may  be  made,  after  excision  of  the 
whole  lip  for  malignant  disease,  by  flaps  made  by  two 
parallel  vertical  incisions,  one  running  downward  from 
the  corner  of  the  mouth ;  the  other  starting  in  the 
cheek  from  a  point  a  little  outside  of  and  below 
the  wing  of  the  nose.  These  incisions  are  connected 
below  by  an  incision  parallel  to  the  margin  of  the  jaw. 
The  two  flaps  are  united  in  the  middle  line  in  such  a 
way  as  to  construct  a  lower  lip.  This  displacement 
modifies  a  little  the  corners  of  the  mouth,  but  this  is 
unimportant.     Another  method  is  to  cut  flaps  in  the 


25 

region  of  the  nasolabial  grooves,  as  is  shown  in  the 
illustration. 

The  upper  lip  may  be  constructed  in  a  somewhat 
similar  way  by  two  lateral  flaps  made  by  parallel  inci- 


IncisioQS  for  flaps  to  reconstruct  the  lower  lip. 

sions  following  the  general  direction  of  the  nasolabial 
furrows.  These  flaps  will  have  the  base  upward  and 
are  turned  inward  towards  the  median  line,  to  make 
the  upper  lip,  very  much  as  the  lower  lip  is  constructed 
by  the  flaps  just  described. 

If  a  portion  of  a  lip  near  the  corner  of  the  mouth  is 
lost  the  absent  portion  may  be  replaced  by  cutting  a 


Incisions  to  make  flap  to  reconstruct  a  portion  of  a  lip. 

triangular  flap  from  the  other  lip,  swinging  it  down- 
ward or  upward  around  the  corner  of  the  mouth  to 
bring  it  into  position.     It  is  also  possible  to  make  a 


26 

lower  lip  by  cutting  a  flap  from  the  neck  with  its  base 
upwards  and  making  a  buttonhole  incision  through  the 
skin  near  the  chin.  Through  this  incision  the  turned- 
up  flap  may  be  thrust.  By  twisting  the  flap  the  skin- 
surface  may  be  directed  outwards.  A  similar  operation 
may  be  done  without  making  a  buttonhole  incision  in 
the  skin  near  the  chin.  Then  the  flap  is  simply 
jumped  across  the  normal  skin  on  the  chin ;  or  it  is 
laid  in  a  groove,  made  by  a  vertical  incision  in  the  tis- 
sues covering  the  chin. 

After  making  new  lips  in  any  of  these  ways  the  edge 
may  be  lined  with  mucous  membrane  by  taking  flaps 
of  mucous  membrane  from  the  inside  of  the  cheeks 
near  the  normal  lip  and  twisting  these  flaps  into  proper 
position.  They  are  then  sutured  to  the  newly  made 
organ. 

It  is  also  possible  to  get  tissue  for  a  lip,  by  the  method 
of  Tagliacozzi,  from  the  arm  by  binding  the  hand  to  the 
head.  A  method  which  I  have  used  satisfactorily  is  to 
transfer  the  skin  of  the  abdomen  to  the  hand  and  then 
transfer  from  the  hand  to  the  lip,  after  the  abdominal 
flap  has  become  united  to  the  hand. 

Portions  of  the  cheek  may  be  made  by  flaps  from 
other  portions  of  the  face  or  from  the  neck.  A  con- 
venient way  sometimes  is  to  turn  up  a  flap  from  the 
neck  and  thrust  it  through  a  buttonhole  incision  along 
the  edge  of  the  lower  jaw.  The  skin  surface  may 
thus  be  turned  inward  and  the  outer  surface  skin- 
grafted.  This  operation  is  not  satisfactory  if  the  skin 
of  the  neck  is  covered  with  a  heavy  beard,  because  the 
hair  grows  into  the  mouth. 

Lecture  VII. — The  Correction  of  Deformed  Noses. 

(Abstract.) 

Many  nasal  deformities  are  quite  insignificant  anatom- 
ically, but  are  the  cause  of  much  distress  to  the  patient. 
Though  there  be  little  or  no  obstruction  to  breathing, 
and  little  deformity  to  the  eye  of  the  observer,  the  dis- 
figurement causes  worry  on  the  part  of  the  patient.  In 
other  cases  the  deformity,  from  congenital  malforma- 
tion, fracture  of  the  bones  and  cartilages,  ulceration  or 
gangrene,  is  so  great  as  t6  greatly  disfigure  the  patient's 


27 


countenance.  Syphilis,  giving  rise  to  necrosis  of  tlie 
bones  and  cartilages  which  form  the  support  of  the 
nose,  is  a  potent  cause  of  nasal  deformity.  Epithelio- 
matous  ulcers  occurring  upon  the  nose  may  render  such 
cutting  operations  necessary  as  will  leave  deficiencies, 
which  must  be  filled  by  operative  treatment. 

Destruction  of  tissue,  from  the  application  of  caus- 
tics, to  relieve  real  or  supposed  malignant  growths,  is  not 
infrequently  the  cause  of  disfigurement.  Some  of  the  dis- 
tortions of  the  nose  are  due  to  deviations  of  the 
cartilaginous  septum.  Many  of  these  deviations  are  the 
result  of  fracture  following  comparatively  insignificant, 
and  perhaps  forgotten,  blows  upon  the  nose.  The 
saddleback  nose  arises  from  a  want  of  proper  develop- 


Saddleback  Nose. 


Tuberous  Nose. 


Angular  Nose. 


ment  of  the  bones  and  cartilages  forming  the  septum. 
A  somewhat  similar  sunken-in-nose  is  found  in  inherited 
syphilis.  These  are  much  less  conspicuous  disfigure- 
ments than  the  dreadful  deformity  of  this  organ,  which 
arises  from  syphilitic  necrosis  of  the  internal  structures 
of  the  nose,  which  give  shape  to  its  external  contour. 
In  these  cases  the  middle  of  the  nose  sinks  inward  be- 
cause of  lack  of  support.  The  tip  of  the  nose,  there- 
fore, rises  and  the  nostrils  instead  of  pointing  down- 
ward look  directly  forward.  The  saddleback  nose,  the 
angular  nose  due  to  undue  prominence  of  the  lower  end 
of  the  nasal  bones,  and  the  nose  with  a  tuberous  lobule 
are  all  amenable  to  operative  treatment.  In  the  saddle- 


28 


back  nose  a  piece  of  metal  or  celluloid  may  be  steril- 
ized and  slipped  underneath  the  skin  in  such  a  way  as 
to  fill  up  the  hollow  on  the  dorsum  of  the  nose,  and 
give  the  organ  a  straight,  or  nearly  straight,  surface 
from  the  forehead  to  the  tip. 

The  sunken  or  saddleback  nose  of  inherited  or  ac- 
quired syphilis  requires  much  more  active  surgical 
intervention ;  at  least  in  the  majority  of  cases.  Here  it 
is  necessary  to  elevate  the  parts;  and  then  support 
them.  Chiselling  portions  of  bone  from  the  nasal  pro- 
cesses of  the  maxillary  bones,  or  from  the  nasal  bones 
themselves  if  they  have  not  been  destroyed  has  been 
adopted.  These  detached  fragments  are  displaced  in 
such  a  manner  as  to  give  support  to  the  nasal  tissues 
which  have  previously  been  elevated  by  subcutaneous 


Twisted  Nose. 


Bent  Nose. 


incisions.  The  introduction  of  intranasal  -supports  of 
metal,  to  hold  up  the  external  nose,  has  been  employed. 
In  syphilitic  cases  foreign  materials  used  for  this  pur- 
pose are  more  apt  to  set  up  irritation  than  in  nonsyph- 
ilitic  cases.  It  is  probably  better  to  build  up  the  dorsum 
by  flaps  taken  from  the  cheeks  or  forehead,  than  by 
using  internal  supports  made  of  metal. 

The  angular  nose  is  usually  remedied  by  the  very 
simple  operation  of  making  an  incision,  and  chiselling 
away  the  redundant  cartilage  and  bone.  It  is  usually 
better  to  make  the  cut  along  the  edge  of  the  nose,  rather 


29 

than  directly  in  the  middle  lioe.  The  elasticity  of  the 
skin  permits  the  surgeon  to  displace  the  flap  laterally, 
and  get  access  to  the  prominence  to  be  removed.  The 
scar,  being  a  little  to  one  side  of  the  anterior  surface  of 
the  bridge  of  the  nose,  is  less  conspicuous  than  if  in  the 
middle. 

Bent  and  twisted  noses  are  remedied  by  incising  the 
septum,  removing  redundant  portions  of  the  septal 
cartilage  and  bones,  separating  the  soft  tissues  of  the 
nose  from  the  bony  supports  beneath  by  the  free  use  of 
a  tenotome,  and  forcing  the  distorted  organ  into  proper 
position.  It  is  held  here  by  means  of  pins  introduced 
through  the  nostril  and  from  the  external  portion  of  the 
nose.  The  use  of  pins  is  often  more  satisfactory  than 
intranasal  splints  or  tubes,  because  the  nostrils  are  kept 
free  from  obstructing  foreign  bodies,  and  can  be  easily 
irrigated  or  sprayed  with  antiseptic  solutions.     In  cor- 


Use  of  pins  to  hold  incised  septum  in  corrected  position. 

recting  bent  or  twisted  noses,  the  surgeon  should  usu- 
ally overcorrect  the  deformity,  because  there  is  a 
tendency  for  the  nose  to  return  to  its  abnormal  position. 
Chisels,  saws,  and  the  surgical  engine  are  instruments 
very  useful  in  correcting  the  septal  deformity  which  is 
often  associated  with   these   external    disfigurements. 


Tarbed  Needlp. 


Surgeons  should  not  forget  the  importance  of  examin- 
ing all  recent  fractures  of  the  nasal  bones  and  cartilages 
with  great  care.  Imperfect  examination  and  conse- 
quent inefficient  treatment  are  the  causes  of  many 
deformed  noses. 


80 

In  removing  cartilaginous  excrescences  upon  the 
septum,  a  long  barbed  needle  is  often  valuable.  It  is 
thrust  into  the  mass,  which  is  thus  steadied,  until  it  is 
excised  with  knife  or  saw.  The  long  needle  gives  the 
surgeon  control  of  the  little  tumor,  and  permits  the 
removal  to  be  quickly  done. 


Ala  of  nose  and  portion  of  upper  lip  made  from  flap  cut  from  the  cheek.  Flap 
doubled  invvard  to  make  naris  by  a  double  stitch  tied  over  a  piece  of  rubber 
tube  placfd  alongside  of  the  bridge  of  the  nose.  (Taken  a  few  days  after 
operation. ) 

Loss  of  the  ala  of  the  nose  may  be  repaired  by  mak- 
ing a  flap  from  tbe  upper  lip  and  cheek,  and  turning 
it  into  the  gap.  Sometimes  it  is  better  to  take  the  new 
tissue  from  the  cheek  alone,  making  the  incisions  in 
the  nasolabial  furrow.  Portions  of  the  nose  have  been 
constructed  from  the  tissues  of  one  of  the  fingers.    This 


31 

may  be  done  by  splitting  a  finger  of  the  left  hand  on 
its  palmar  surface,  removing  the  phalanx,  and  stitching 
the  laid-open  soft  tissues  to  the  stump  of  the  nose.  The 
nail  is  removed  either  before  or  after  the  plastic  opera- 
tion which  attaches  the  digit  to  the  nose.  After  the 
lapse  of  about  two  weeks  the  finger  is  amputated  from 
the  hand.  Nearly  a  complete  nose  has  been  made  by 
using  a  finger  in  a  somewhat  similar  way.  The  color 
of  the  skin  of  the  hand  is  apt  to  difi'er  from  that  of  the 


Portion  of  ala  of  nose  made  from  tip  of  finger.  (Dr.  J.  P.  Tunis'  ca=e.)  The 
notch  in  the  new  ala  was  subsequently  repaired  by  the  author  with  a  flap 
taken  from  the  cheek. 

face.  Flaps  may  be  taken  from  the  forehead,  with  or 
without  periosteum,  and  turned  or  twisted  downward 
to  close  a  gap  on  the  top  or  side  of  the  nose.  The  color 
is  then  more  natural. 

The  contour  of  a  syphilitic  nose  may  be  improved 
by  a  transverse  incision  across  the  depressed  nose  at 
the  deepest  part  of  the  furrow  above  the  lobule  of  thfr 


32 


-organ.  This  incision  opens  the  nasal  chambers  and 
•enables  the  surgeon  to  pull  down  the  tip  of  the  nose, 
so  that  the  plane  of  the  nostrils  is  horizontal,  as  it  nor- 
mally should  be.  The  great  gap  left  between  the  root 
of  the  nose  and  the  tip  must  then  be  filled.  I  have 
done  this  quite  satisfactorily  by  taking  flaps  from  the 
cheeks  and  turning  them  inward  toward  the  middle 
•line,  so  that  the  skin-surface  presented  toward  the  nasal 


Three  diagrams  showing  a  sunken  syphilitic 
nose  and  one  method  of  repairing  it. 

cavity.  The  tissue  of  the  forehead  was  then  brought 
downward  to  cover  these  flaps,  and  make  the  mass  of 
tissue  thick,  so  as  to  give  rigidity  to  the  newly  formed 
portion  of  the  nose.  Another  method  is  to  make  a  V- 
shaped  incision  between  the  eyes  with  the  point  of  the 
V  upward,  and  displace  this  flap  downward  to  fill  the 
gap  left  by  the  original  transverse  incision,  which  was 
made  to  bring  down  the  point  of  the  nose.  This  flap 
is  scarcely  rigid  enough,  but  may  be  held  in  position 


33 

by  spectacles  supplied  with  a  spring,  like  eyeglasses. 
Many  modifications  of  these  two  plans  will  suggest 
themselves  to  operators. 

I  have  made  a  forehead  flap  containing  periosteum 
and  a  thin  shaving  of  bone,  turned  that  downward  and 
thrust  it  through  a  transverse  buttonhole  at  the  base  of 
the  nose.  This  was  done  with  the  hope  of  giving  more 
solidity  to  the  new  dorsum. 


Patient  deformed  by  burns  so  that  the  nose  was  twisted  to  the  left,  the  naris 
closed,  the  lips  ererted  and  the  eyelids  distorted.  Much  improvement  was 
obtained  by  a  series  of  operations. 

The  columella  of  the  nose  may  be  made  by  two  ver- 
tical incisions  extending  downward  through  the  upper 
lip.  The  central  portion  of  the  lip  is  then  turned  up- 
ward and  stitched  to  the  tip  of  the  nose  in  such  a  way 
as  to  make  a  partition  between  the  two  nostrils.  The 
gap  in  the  Up  is  then  closed  by  stitches  as  in  hare-lip. 
The  mucous  membrane  which  then  covers  the  external 


34 

surface  of  the  new  columella  soon  assumes  an  appear- 
:ance  similar  to  that  of  skin.  I  have  on  the  cadaver 
<3onstructed  a  satisfactory  columella  by  cutting  a  verti- 
cal piece  from  the  inner  surface  of  the  lip  and  turning 
it  upwards  through  a  transverse  buttonhole  made  at  the 
junction  of  the  nose  and  lip. 

It  is  probable  that  the  ala  of  the  nose  may  be  lined 
"with  mucous  membrane  in  a  similar  manner.  This  may 
be  necessary  when  occlusion  of  the  naris  takes  place 
.after  reconstruction  of  an  ala.  A  portion  of  mucous 
membrane  and  muscle  may  be  cut  from  the  inner  sur- 
face of  the  lip  and  turned  upwards  through  a  button- 
hole made  in  the  lip  at  the  lower  border  of  the  nostril. 
It  is  perhaps  possible  to  make  the  columella  from  the 
•dorsum  of  the  nose,  by  cutting  a  flap  containing  peri- 
osteum from  over  the  nasal  bones  themselves,  and 
thrusting  this  cutaneo-periosteal  flap  through  a  trans- 
verse buttonhole  made  near  the  tip  of  the  nose.  The 
■flap  should  then  be  stitched  to  the  upper  portion  of 
the  lip. 

This  same  method  might  perhaps  be  employed  in 
the  treatment  of  saddleback  noses  by  thrusting  flaps 
cut  from  the  cheek  through  buttonholes  made  in  the 
skin  at  the  side  of  the  nose.  If  the  cuticle  is  removed 
from  these  cheek  flaps,  they  would  probably  become 
adherent  to  the  deeper  tissues  of  the  nose,  and  build 
up  a  mass  of  connective  and  fibrous  tissue  underneath 
the  skin  at  the  front  of  the  nose.  A  hollow  creating 
the  saddleback  condition  could  probably  be  thus  oblit- 
erated. These  operations  I  have  only  tried  upon  the 
cadaver,  but  they  seem  to  promise  success. 

Lecture  VIII. — The  Construction  of  New  Noses. 

(Abstract.) 

Rhinoplastic  operations,  for  the  construction  of  an 
entire  nose  or  a  portion  of  that  organ,  are  required  to 
repair  the  damages  of  syphilis  and  lupus  and  of  inten- 
tional and  accidental  mutilations.  American  and  Con- 
tinental surgeons  have  very  little  experience  with  these 
operations,  except  in  cases  due  to  syphilis  and  lupus. 
English  surgeons  in  India  have  very  many  patients 
with   the    cartilaginous   portion   of  the    nose    cut  ofl" 


35 

by  sharp  instruments.  This  mutilation  is  frequently 
adopted  in  India  as  a  means  of  revenge.  Keegan  states 
that  the  number  of  such  mutilations  effected  in  a  single 
year  in  India  is  unknown.  That  it  must  be  large  is 
■evident  from  his  statement  that  in  the  year  1897  there 
were  152  rhinoplastic  operations  performed  in  that 
country.  -In  a  single  evening  he  saw,  while  riding 
through  one  of  the  native  cities,  as  many  as  three  or 
four  women  with  mutilated  noses,  sitting  near  their 
huts.  As  a  consequence  of  this  distribution  of  rhino- 
plastic  work,  American  and  European  surgeons  have 
had  much  less  experience  than  Indian  surgeons.  The 
■cases  seen  outside  of  India  are  usually  much  more 
■difficult  to  bring  to  a  satisfactory  conclusion  by  opera- 
tion, because  the  tissues  which  remain  have  been 
distorted  and  altered  by  the  syphilitic  or  tubercular 
ulceration  which  has  destroyed  the  nose.  In  many  of 
these  nasal  deficiencies,  due  to  disease,  the  internal 
bony  and  cartilaginous  structures  have  been  entirely 
destroyed.  In  some  instances  even  the  nasal  bones 
which  support  the  nose  at  its  bridge  are  also  absent,  as 
the  result  of  the  syphilitic  necrosis. 

Until  recent  years  the  technic  of  total  rhinoplasty  was 
somewhat  imperfect ;  and,  as  a  consequence,  surgeons 
undertook  the  construction  of  a  nose  with  considerable 
hesitation.  More  recent  studies  and  the  advantages  of 
aseptic  surgery  have  improved  conditions  to  such  an 
■extent  that  these  operations  are  now  undertaken  with 
much  more  certainty  of  obtaining  an  improvement  in 
the  patient's  appearance.  A  very  great  deal  can  be  done 
when  only  the  soft  parts  of  the  external  nose  have  been 
cut  off.  Quite  a  satisfactory  gain  is  possible,  even  in 
■cases  greatly  deformed  by  cicatricial  contraction,  subse- 
quent to  syphilitic  ulceration  of  the  hard  and  soft  parts. 
In  the  latter  cases  the  main  difficulty  is  to  get  support 
to  the  flaps  of  skin  which  are  used  to  make  the  new 
nose.  Metallic  supports  and  bridges  of  various  sorts 
have  been  employed  to  hold  up  and  give  the  requisite 
projection  forwards  of  the  flaps  of  skin  which  represent 
the  new  nose.  In  some  cases  these  have  been  worn  for 
a  number  of  years  and  apparently  with  satisfaction.  In 
others  they  have  set  up  irritation,  which  has  finally  led 
to  their  removal. 


36 

Portions  of  bone  have  been  chiseled,  from  the  nasal 
bones  and  from  the  superior  maxillary  bones,  and  dis- 
placed in  such  a  way  as  to  hold  the  integument  for- 
ward. These  osteoplastic  operations  have  been  to  a 
certain  extent  satisfactory.  Oilier,  Koenig  and  Israel 
have  made  interesting  suggestions  in  this  connection. 
Sabine,  of  New  York,  constructed  a  new  nose  from  a 
finger,  which  he  attached  to  the  sides  of  the  chasm  left 
by  the  loss  of  the  nose.  The  finger-nail  was  removed 
and  the  palmar  surface  of  the  finger  split  so  as  to  form 
lateral  flaps.  The  hand  was  then  applied  to  the  face 
and  the  finger  stitched  to  the  edges  of  the  nasal  cavity. 
After  circulatory  connection  was  established,  the  finger 


Langenbeck  and  Oilier  split  the  nose  vertically,  laid  the  soft  parts  to  each 
side,  and  then  sawed  bony  flaps  from  the  edges  of  the  nasal  aperture  above 
and  below  on  each  side.  They  then  bent  these  bony  flaps  forward  to  give 
support  to  the  frontal  flap  or  the  replaced  soft  structures. 

was  amputated  from  the  hand  through  the  first  phalanx ; 
and  the  end  of  the  portion  of  finger,  left  attached  to  the 
face,  was  bent  at  the  joint  between  the  first  and  second 
phalanx,  so  as  to  make  the  end  of  the  nose  and  its 
columella.  A  number  of  minor  operations  were  subse- 
quently done  to  improve  the  shape  of  the  new  nose. 

The  usual  methods  of  rhinoplasty  are  the  Italian,  in 
which  the  tissues  of  the  arm  are  attached  to  the  stump 
of  the  nose ;  the  French — sometimes  called  the  German 
— method,  in  which  the  new  organ  is  constructed  from 
flaps  taken  from  the  cheeks ;  and  the  Indian  method, 
in  which  the  skin  of  the  forehead  is  utilized  in  the 
nasal  reconstruction. 


87 


The  Italian  method  was  brought  to  the  notice  of 
surgeons  in  1597  by  the  Latin  treatise  of  Tagliacozzi. 
Before  that  time,  however,  rhinoplastic  operations  were- 


Diagrams  of  Serre's  method  of  rhiaoplasty 


Diagram  showiug  Keegan's  outline  for  the  frontal  flap  in  rhinoplasty.    AVhen- 
°  the  flap  is  rotated  downward  the  point  A  is  stitched  at  A'  and  B  at  £  . 

performed  by  Sicilian  operators.  A  brief  reference  is 
found,  it  is  said,  in  a  publication  of  Benedictus.  dated 
1497.     Tagliacozzi's  method  was  subsequently  modified 


38 


in  various  minor  particulars,  and  is  sometimes  used  at 
the  present  day.  In  fact,  flaps  are  taken  from  the  arm 
at  times  for  reconstructing  other  portions  of  the  face, 
such  as  the  hps.  Taghacozzi  himself  speaks  of  this 
application  of  his  method,  and  gives  illustrations  of  it. 
The  brachial  method,  as  it  may  be  called',  of  Taglia- 
cozzi,  is  tedious  to  the  patient  and  requires  a  more  or 
less  complicated  apparatus  for  holding  the  arm  to  the 
face  during  the  time  necessary  for  adhesion  to  take  place. 
Hence,  either  the  frontal  method  used  in  India  from  a 


Diagram  of  Roberts's  nifthod  of  recorstructing  a  sunken-in-nose.  The  dotted 
lines  indicate  the  flaps  taken  from-  the  chetks  to  cover  the  opening  into 
the  nasal  chambers  left  by  the  detachment  and  drawing  down^ward  of  the 
cartilaginous  nose. 

very  early  time,  or  that  in  which  flaps  are  taken  from 
the  cheeks,  is  more  usually  adopted. 

Keegan  has,  as  the  result  of  his  great  experience  in 
India,  modified  the  usually  described  method  of  frontal 
rhinoplasty.  He  cuts  a  flap  from  the  forehead,  with 
its  pedicle  near  the  supraorbital  notch  of  one  eye,  ex- 
tending obliquely  upward  across  the  forehead.  The 
upper  border  of  the  flap  has  a  projection,  from  which 
he  constructs  the  columella  of  the  nose.     He  first  makes 


39 

a  pattern  of  the  flap  by  using  a  piece  of  banana  leaf, 
which  is  flexible  and  supple.  Having  made  this  pat- 
tern, he  cuts  from  stout  brown  paper  an  exact  dupli- 
cate in  shape.  This  is  fixed  to  the  forehead  by  an  ad- 
hesive materia],  so  as  to  render  it  easy  to  make  a  flap, 
exactly  satisfactory  both  as  to  size  and  shape.  The 
soft  tissues  over  the  nasal  bones  are  then  converted  into 
two  flaps,  which  are  turned  downward  upon  a  hinge, 
as  it  were,  near  the  inferior  border  of  the  nasal  bones. 
This  maneuver  puts  the  skin-surface  of  these  flaps  in- 
wards towards  the  nasal  cavity.     The  frontal  flap  is 

^^ 


The  cheek  flaps  sutured  to  close  the  opening. 

"then'cut  and,  by  twisting  its  pedicle,  it  is  carried  down- 
ward so  as  to  cover  the  denuded  nasal  bones  and  the 
raw  surface  of  the  turned-down  tissues,  which  pre- 
viously covered  those  bones.  The  columnar  portion 
of  the  frontal  flap  is  then  properly  sutured  into_  a 
groove  or  bed  at  the  upper  part  of  the  superior  lip. 
Sutures  are  applied  to  close  the  frontal  wound  and  fix 
the  edges  of  the  flaps  in  proper  relation.  Drainage- 
tubes  are  inserted  in  the  newly-formed  nostrils.     The 


40 


pedicle  at  the  root  of  the  frontal  flap  is  divided  at  the 
end  of  about  ten  days. 

The  object  in  using  the  tissue  covering  the  nasal 
bones  to  form  the  internal  surface  of  the  nostrils  is  to 
prevent  contraction  of  the  nostrils.  These  underlying 
flaps  also  give  support  and  strength  to  the  new  nose,  so 
that  it  is  less  likely  to  beconae  flattened. 

Portions  of  noses  may  be  constructed  by  various 
rhinoplastic  procedures,  but  they  need  not  be  further 
discussed  here.     Some  of  them  have  been  already  men- 


The  dotted  lines  show  the  outlines  of  the  two  frontonasal  flaps. 

tioned  in  the  previous  lecture.  The  tissues  of  the  lips 
and  cheeks  may  be  utilized  for  the  formation  of  the 
necessary  flaps,  which  are  then  displaced,  so  as  to  fill 
the  gaps  which  are  the  cause  of  the  nasal  deformity. 

The  construction  of  a  portion  of  the  nose  in  cases  of 
sinking-in,  due  to  syphilitic  destruction  of  the  internal 
cartilaginous  and  bony  supports,  is  often  a  difiicult 
problem.  In  these  cases  the  middle  portion  of  the  nose 
is  greatly  depressed  and  the  tip  of  the  nose  turned  up- 
wards so  that  the  nostrils  look  forward  instead  of  down- 
ward.    In  some  cases  the  nasal  bones  are  destroyed, 


41 

but  they  often  remain  uninvolved  by  the  syphilitic 
necrosis.  I  have  recently  reconstructed  such  a  nose  in 
a  very  satisfactory  manner  by  a  combination  of  plastic 
procedures  which  is,  so  far  as  I  know,  new.  The  first 
step  was  to  make  a  transverse  incision  in  the  hollow 
above  the  tip  and  alae  of  the  nose,  where  the  depres- 
sion due  to  cicatricial  contraction  and  want  of  support 
was  the  greatest.  This  enabled  me  to  pull  down  the 
lower  end  of  the  nose  and  bring  it  forward  so  that  the 
nostrils  looked  downward  and  the  tip  of  the  nose  had  its 


The  frontonasal  flaps  sutured  on  top  of  the  cheek  flaps. 

normal  projection  forwards.  This  left  a  large  openiDg 
between  the  cartilaginous  nose  and  the  lower  end  of  the 
nasal  bones.  This  space  was  covered  by  lateral  flaps 
cut  from  the  cheeks  and  turned  inward  towards  the 
middle  line  with  the  skin  surfaces  towards  the  nasal 
chambers.  These  flaps  should  be  cut  in  the  line  of  the 
nasolabial  furrow  in  order  that  the  linear  scar  may  cor- 
respond with  this  line  more  or  less  accurately  and  there- 
fore be  comparatively  inconspicuous. 

After  these  flaps  had  become  united  in  this  position, 


42 

the  irregularity  due  to  the  twisting  of  their  pedicles  was- 
removed  by  a  small  plastic  operation  on  each  side. 
The  next  major  step  was  to  make  two  diverging  inci- 
sions from  the  middle  of  the  forehead,  downwards  and 
outwards,  in  the  manner  shown  in'the  diagram.  Two 
other  incisions  were  made  just  above  the  granulating 
surface,  situated  at  the  point  where  the  cheek-flaps 
had  been  united  in  the  middle  line.  A  median  vertical 
incision  was  made  to  connect  the  apices  of  the  inverted 
V's  made  by  these  four  incisions.  The  two  flaps  thus 
made  over  the  nasal  and  frontal  bones  were  then  dis- 
sected from  the  underlying  tissues  and  turned  down- 
ward so  that  the  upper  point  of  the  right  flap  could  be 
attached  to  the  base  of  the  left  ala,  and  the  uppermost 
point  of  the  left  flap  turned  over  to  the  right  side  of 
the  patient,  so  as  to  fit,  against  the  other  flap,  below  the 
inner  canthus  of  the  right  eye.  The  wound  left  in  the 
forehead  was  then  closed  vertically  and  numerous  su- 
tures applied  to  hold  the  displaced  flaps  in  their  new 
positions. 

This  maneuver  covered  the  granulating  surface  of 
the  cheek  flaps  that  closed  the  opening  in  the  nose  ^ 
and  gave  thickness  and  solidity  in  the  region  where 
firmness  is  so  essential,  in  order  to  maintain  the  outline 
of  the  organ.  A  number  of  minor  operations  were 
subsequently  necessary  to  get  rid  of  the  irregularities 
produced  by  the  coaptation  of  so  many  flaps,  but  a 
very  satisfactory  outcome  has  resulted.  The  new  nose 
has  a  fair  degree  of  prominence  and  the  nostrils  and 
alae  are  in  proper  position  and  of  normal  shape.  The 
dorsum  of  the  nose,  while  not  beautiful,  is  free  from 
the  marked  and  disfiguring  depression  which  formerly 
existed. 

In  order  to  make  the  prominence  of  the  nose  and 
upper  lip  relatively  greater,  a  portion  of  the  lower  lip 
was  removed  by  a  V-shaped  incision. 

Lectuee  IX. — TJie  Operative  Treatment  of  Deformed  or 
Deficient  Ears. 

(Abstract.) 

Operations  for  the  relief  of  aural  disfigurement  have 
received  very  little  attention  until  within  the  last  six  or 
eight  years.     This   is   rather   remarkable  because  the 


43 

deformities  are  quite  conspicuous  and  the  operations 
for  their  relief  free  from  serious  risk.  It  is  the  more 
strange  because  Itahans  of  the  time  of  Tagliacozzi  and 
earlier  did  plastic  operations  upon  the  ear,  and  it  is 
said  by  Szymanowski  that  such  operations  are  men- 
tioned in  Sanscrit  writings. 

The  ears  of  prize-fighters  often  receive  injuries  which 


Congenital  deformity  of  ear,  treated  by  elliptical  incision  and  bending  of  the- 
cartilage. 

result  in  permanent  cicatricial  deformity.  Sexton  called 
attention  some  years  ago  to  the  fact  that  the  ancient 
Greeks  must  have  been  familiar  with  deformed  ears  in 
boxers,  because  the  characteristic  disfigurement  is^ 
according  to  him,  shown  in  statues  representing  ancient 
Greek  pugilists. 

The  external  ear  is  quite  often  the  seat  of  incised  and 


44 

lacerated  wounds  which  require  accurate  suturing  to 
reproduce  the  normal  outline.  The  auricle  may  be 
torn  almost  completely  from  the  skull  and  yet  be  easily 
restored  to  its  position  by  a  few  sutures.  Completely 
detached  portions  should  be  cleansed  and  sutured  into 
position,  even  if  some  time  has  elapsed  since  the  acci- 
dent. Union  may  sometimes  be  obtained  even  in  these 
unfavorable  cases. 

Sloughing  after  frost-bite  is  a  not  unusual  cause  of 
aural  disfigurement.  Plastic  operations  may  improve 
the  appearance  of  the  organ.  A  common  injury  is 
laceration  of  the  lobule  from  earrings  having  been  torn 
out  of  the  ear  by  children,  grasping  at  the  trinket,  while 
being  carried  by  their  mothers.  The  fissure  so  made 
may  be  easily  closed,  even  if  cicatrization  has  previ- 
ously occurred,  by  freshening  the  edges  of  the  cleft  and 
applying  sutures.  I  have  operated  when  the  ear  has 
had  several  such  cicatrized  tears  in  its  lobule.  A  simi- 
lar plastic  operation  is  necessary  after  the  removal  of 
the  keloid  growths  that  occasionally  result  after  piercing 
the  ears  for  earrings.  A  little  ingenuity  will  greatly 
improve  such  cases,  as  I  have  proved  in  operating 
upon  a  good  many  patients. 

Burns  of  the  side  of  the  head  cause  sloughing  and 
cicatricial  disfigurement.  Pancoast  many  years  ago 
made  a  new  lobule  to  an  ear  by  two  crescentic  incisions 
which  enabled  him  to  lift  up  sufficient  tissue  to  con- 
struct a  lobule. 

A  great  loss  of  tissue  from  sloughing  may  need  to  be 
replaced  by  taking  a  flap  from  the  hand,  applied  to  the 
side  of  the  head  until  circulation  has  been  established. 
The  tissue  may  then  be  cut  from  the  hand.  A  large 
piece  of  tissue  may  be  transferred  from  the  abdomen. 
In  such  an  operation  the  graft  would  first  be  attached 
to  the  hand,  and  two  weeks  later  cut  from  the  ab- 
domen ;  and  the  hand  would  then  be  applied  to  the 
side  of  the  head  in  such  a  way  as  to  permit  the  new 
tissue  to  be  attached  to  the  region  of  the  ear. 

Irregularities  of  the  auricle,  enchondromatous  nod- 
ules in  the  neighborhood  of  the  ear,  and  fistulous 
openings  occur  as  congenital  defects.  They  are  due  to 
irregular  coalescence  of  the  branchial  arches  and  im- 
perfect closure  of  the  branchial  clefts.    Sometimes  there 


45 

is  a  deficiency  of  cartilage  in  the  pinna  which  allows 
the  external  ear  to  assume  abnormal  positions  on  ac- 
count of  its  flaccid  character.  I  recently  operated  upon 
the  case  of  this  sort  which  is  shown  in  the  figure. 
At  other  times  the  cartilage  in  the  pinna  may  become 
buckled  or  bent  during  birth  or  soon  afterwards,  and 
asymmetrical  ears  result  from  want  of  correction  of 
this  abnormality.  The  lack  of  cartilaginous  material 
may  perhaps  be  compensated  for  by  excising  a  portion 
of  the  skin  back  of  the  ear  and  stitching  it  to  the  side 
of  the  head.  It  has  been  suggested  that  a  thin  sheet 
of  platinum  or  other  material  be  inserted  beneath  the 
skin,  to  give  rigidity  and  a  proper  contour  to  the  external 
ear.  This  could  perhaps  be  bent  into  shape,  even  after 
the  tissues  had  healed  over  it.  The  deformity  due  to 
bending  or  buckling  of  the  cartilage  may  be  remedied^ 
if  the  child  is  treated  when  young,  by  bending  the 
organ  in  the  opposite  direction  and  holding  it  there 
by  means  of  adhesive  strips,  or  some  form  of  spring 
going  across  the  top  of  the  head  and  having  a  pad  ta 
press  upon  the  ear.  If  the  deformity  is  slight,  the  con- 
tracting influence  of  collodion  may  be  utilized. 

Exceedingly  large  ears,  due  to  a  sort  of  hypertrophy 
of  all  the  tissues,  occasionally  require  curtailment.  This 
may  be  done  satisfactorily  by  excising  a  V-shaped  por- 
tion of  the  auricle  with  the  base  of  the  V  towards  the 
outer  margin  of  the  organ.  Careful  suturing  will  restore 
the  general  outline  and  maintain  the  regularity  of  the 
natural  elevations  and  depressions.  The  exsection  of 
a  crescentic  piece  from  the  central  part  of  the  pinna,  with 
a  tongue-shaped  process  extending  from  the  convex 
border  of  the  crescent  to  the  border  of  the  pinna,  makes 
a  rather  neater  operation  and  restores  more  accurately 
the  normal  contour.  This  method  was,  I  believe,  first 
suggested  by  Dr.  Parkhill.  Such  elephantine  ears  are 
greatly  improved  by  these  operations.  Flaring  or  out- 
standing ears  are  very  ugly,  especially  when  the  flaring 
condition  is  associated  with  great  size.  Such  ears  may 
be  brought  closer  to  the  head  by  the  excision  of  an 
elliptical  piece  of  tissue  behind  the  auricle,  and  the  in- 
sertion of  stitches  so  as  to  draw  the  cartilage  nearer  to 
the  surface  of  the  cranium.  The  elliptical  portion  re- 
moved should  have  its  long  diameter  in  the  vertical 


46 

direction  and  should  be  wide  at  the  point  where  it  is 
desired  to  draw  the  cartilage  inward  to  the  greatest 
extent.  The  portion  removed  should  be  quite  large  and 
its  outer  edge  on  the  posterior  surface  of  the  pinna 
should  extend  far  outwards  as  the  amount  of  retraction 
desired  is  greater. 

The  inner  border  of  the  ellipse  on  the  surface  of  the 
skull  should  be  comparatively  close  to  the  bottom  of 
the  furrow  between  the  ear  and  the  head.  By  the 
insertion  of  stitches  in  an  oblique  direction  the  axis  of 
the  ear  can  be  somewhat  changed. 

Some  operators  have  removed  only  the  skin  and  sub- 


Biagram  of  method  of  Parkhill  for  reducing  size  of  ear. 
piece  to  be  excised. 


Dotted  lines  sliow 


cutaneous  tissue;  others  have  taken  out  the  entire 
thickness  of  the  pinna,  including  the  cartilage  and  the 
skin  on  both  the  back  and  front.  It  is  probably  best 
to  remove  a  large  portion  of  skin  and  subcutaneous 
tissue  on  the  posterior  surface  of  the  ear  and  the  skull, 
and  to  excise  a  wedge-shaped  portion  of  the  cartilaginous 
structures;  but  the  cartilaginous  piece  which  is  re- 
moved should  be  much  narrower  than  that  cut  out  of 
the  skin.  This  method  I  have  used  satisfactorily.  It 
is  usually  not  necessary  to  carry  the  incision  through 
the  skin  on  the  front  of  the  ear. 


47 

Congenital  absence  of  the  ears  may  be  treated  by  the 
adoption  of  an  aluminum  ear  properly  tinted  and  held 
in  place  by  a  spring  inserted  in  a  slit  in  the  soft  tissues. 
Westlake  adapted  such  a  contrivance  to  a  man's  head, 
and  the  patient  was  able  to  unlock  the  artificial  organ 
and  remove  it.  This  was  done  by  means  of  a  spring 
situated  behind  the  artificial  ear. 


Method  suggested  by  Szymanowski  for  constructing  an  auricle  in  congenital 
absence  of  the  external-'ear.  A.  Dotted  lines  show  incisions  by  which 
the  ^kin  is  raised  and  doubled  so  as  to  mate  a  crude  auricle.  The  posterior 
flap  is  thrust  under  the  anterior  one  and  sutured  by  through-and-through 
sutures.  B.  Shoivs  incisions  made  at  a  subsequent  operation  to  model 
the  crude  auricle  into  more  perfect  shape. 

Szymanowski  has  suggested  the  making  of  a  cutaneous 
ear  in  these  cases  of  congenital  absence  of  the  organ. 
The  diagram  shows  the  incisions  for  the  reconstruction 
of  a  rudely  shaped  ear  which  is  afterwards  to  be  mod- 
elled by  smaller  incisions  and  proper  suturing.  It 
seems  as  if  it  might  be  possible  to  insert  an  aseptic 
piece  of  metal  into  such  a  cutaneous  reconstruction  to 
give  it  risiditv  and  a  contour  like  that  of  an  ear. 


Lecture  X. — The  Cosmetic  Surgery  of  the  Eyes. 

(Abstract.) 

Much  can  be  done  for  improving  disfiguring  condi- 
tions of  the  eyeball  and  eyelids.  One  of  the  most 
common  of  the  ocular  conditions  causing  an  unseemly 
expression  of  the  countenance  is  strabismus.  The 
internal  form  is  usually  associated  with  hyperopia 
and  requires  proper  correction  of  the  refractive  condi- 


48 

tion,  in  addition  to  section  of  the  internal  rectus 
muscle.  Failure  to  wear  lenses  to  correct  the  refrac- 
tive defect  causes  not  infrequently  a  return  of  the 
cross-eye  condition.  I  have  now  under  my  care  a 
patient  in  which  the  strabismus  returned,  apparently 
from  neglect  of  this  precaution  on  the  part  of  the  former 
operator.     The  various  operations  for  correcting  internal 


New  eyelid  made  with  flap  from  forehead.      Photograph  taken  three  weeks 
after  operation. 

and  external  squint,  or  strabismus,  by  cutting  the 
muscles,  advancing  the  tendons,  or  by  a  combination  of 
both  operations,  need  not  be  discussed  in  detail ;  they 
are  familiar  to  all  ophthalmic  surgeons. 

Disfiguring  white  spots  upon  the  cornea  may  be 
tinted  with  India  ink.  This  little  operation  must  be 
frequently  repeated  in  order  to  get  the  tint  of  the  scar- 
tissue  sufficiently  dark.     Such  eyes  are   defective  in 


49 

vision  and  the  tattooing  is  simply  to  make  the  con- 
spicuous white  spot  of  such  a  color  that  it  will  not 
attract  attention. 

Blind  eyes,  due  to  injury  or  any  other  lesions  which 
destroy  the  appearance  and  shape  of  the  globe,  may  be 
covered  with  artificial  eyes  of  glass  so  colored  as  to 
correspond  with   the   normal   eye   on  the   other  side. 


-,-:w'Sfe«.£l'?8«fi«ii3»»*-J 


New  eyelid   made    with    flap  from    forehead,    takeu  at    a    later    date     than 
other  figure. 

Anterior  section  may  be  required,  if  there  is  a  promi- 
nence of  the  diseased  eyeball  due  to  anterior  staphy- 
loma. Mules's  operation,  in  which  a  glass  ball  is 
inserted  into  the  eviscerated  sclera  to  give  sufficient 
prominence  to  the  globe,  is  a  very  satisfactory  method  of 
maintaining  the  prominence  and  the  motions  of  the 
eyeball.  The  glass  shell  or  eye  placed  in  front  of  this 
has  a  much  more  normal  appearance  than  when  it  is 


50 


used  after  the  globe  of  the  eye  has  been  entirely  re- 
moved. A  small  eye  due  to  atrophy  may,  if  it  is  blind, 
be  made  to  appear  larger  by  wearing  a  strong  convex 
lens  in  front  of  it.  In  front  of  the  opposite  eye  a  piece 
of  plain  glass  may  be  inserted  in  the  spectacle  frame. 


Ectropion  of  upper  eyelid,  due  to  cicatrization  after  avulsion  of  entire  scalp. 
Operation  consisted  in  using  flaps  from  temporal  region  and  side  of  nose. 
Incisions  marked  with  ink.  Head  shows  result  of  skin-graftiog  on  ulcer- 
ated surface. 

In  conditions  of  exophthalmos,  and  especially  in  that 
form  due  to  the  disease  called  exophthalmic  goiter,  the 
disfiguring  bulging  of  the  eyes  may  be  relieved  by 
stitching  the  outer  canthus  of  the  eyelids  so  as  to  lessen 


51 

the  size  of  the  palpebral  fissure.  This  operation  should 
not  be  done  until  the  active  symptoms  of  the  disease 
have  subsided.  At  any  time,  if  the  bulging  of  the  eye 
persists,  the  removal  of  a  little  of  the  mucous  membrane 
at  the  outer  angle  of  the  eyelids  and  the  insertion  of  a 
couple  of  stitches  will  so  cover  the  eyeball  as  to  make 
the  bulging  disappear. 


Excision  of  epithelioma  below  the  eye.    Flap  from  temple  used  to  prevent 
eetijBpioD.    Outline  of  flap  marked  with  ink. 


There  are  many  operations  possible  upon  the  eye- 
lids Avhich  improve  the  appearance  of  the  upper  part 
of  the  face.  The  congenital  condition  called  epican- 
thus,  in  which  folds  of  skin  extend  over  the  inner 
angles  of  the  eyelids,  is  improved  by  the  removal  of  a 
vertical  ellipse  of  skin  at  the  root  of  the  nose.  Drooping 
of  the  eyelids,  technically  called  ptosis,  is  remediable 
by  removing  a  section  of  the  skin  of  the  upper  lid   or 


52 


giving  a  new  attachment  to  the  elevator  muscle.  Warts 
and  other  tarsal  tumors  are  very  disfiguring,  but  most 
of  them  are  easily  removed  by  simple  operations. 

Wounds  of  the  eyelids  should  be  made  aseptic  and 
sutured  with  care  to  prevent  cicatricial  distortion.     One 


Epithelioma  near  outer  cantlius  removed,  the  space  tilled  in  with  flap  from 
temple,  shavings  of  skin  applied  to  surface  lett  by  transfer  of  the  flap. 

of  the  Ugliest  of  the  deformities  of  the  eyelids  is  ever- 
sion  of  the  lid  caused  by  cicatricial  contraction  follow- 
ing burns,  lupus,  or  ulceration.  Thoughtless  surgeons 
sometimes  cause  this  deformity  by  removing  tumors  of 


53 

the  face  and  placing  their  incisions  so  that  cicatricial 
contraction  drags  the  lower  lid  downwards  or  the  upper 
lid  upwards.  This  contingency  should  always  be  recol- 
lected in  operations  in  the  neighborhood  of  the  eyelids. 
If  the  incisions  cannot  be  placed  in  such  a  way  as  to 
make  the  drag  of  the  cicatrix  operate  so  as  not  to  dis- 
turb the  position  of  the  eyelids,  a  plastic  procedure  to 
transfer  the  tension  to  another  position  should  be 
adopted  after  the  excision  of  the  growth.  Adhesion  of 
the  eyelids  to  the  eyeball  after  burns  of  the  conjunctiva 
are  very  diflBicult  to  repair  with  satisfaction.  Many  of 
them,  however,  may  be  relieved  by  plastic  operations 
upon  the  conjunctiva  or  the  transplantation  of  skin  or 
mucous  membrane.  These  conditions  of  symblepharon 
tax  the  ingenuity  of  the  surgeon.  Ankyloblepharon  is 
another  deformity  difficult  to  deal  with  surgically.  In 
it  the  two  eyelids  are  united  by  cicatricial  adhesion. 
Various  operations  have  been  devised  and  are  more  or 
less  successful. 

The  plastic  procedures  required  to  make  new  eyelids, 
after  their  removal  by  sloughing  or  accident,  or  to  fill 
in  a  space  left  by  the  replacement  of  an  eyelid  which 
has  been  dragged  outwards  so  as  to  cause  ectropion, 
must  be  performed  in  accordance  with  the  principles 
of  plastic  surgery  already  laid  down.  The  various 
forms  of  skin  grafting  will  be  of  some  value,  but  as  a 
rule  it  is  necessary  to  turn  a  flap  of  skin  and  subcu- 
taneous tissue  into  the  gap  left  by  replacing  the  eyelid. 
The  space  left  by  the  removal  of  this  flap  may  then 
with  advantage  be  covered  with  skin-grafts.  It  is 
usually  better  to  thus  utilize  the  skin-grafting  process 
for  covering  the  original  seat  of  the  flap  than  to  depend 
on  it  for  lessening  the  tendency  to  cicatricial  con- 
traction. 


COLUMBIA   UNIVERSITY   LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

' 

1 

C28(2SI)IOOM 

i 

R541 
1900 


Roberts      ^^^^ent  of  congenxtal 
&  patholog3£al^£igiL_^-^--^ace. 


I900 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  523  R541  1900  C.1 

The  surgical  treatment  of  conqenital  and 
IIIIIIHII 


2002235595 


